Earache - TriageLogic

Earache

Office Hours Telephone Triage Protocols | Pediatric | 2020

DEFINITION

Pain or discomfort in or around the ear Older child reports an earache Younger child acts like he did with a previous ear infection Excluded: Ear pain caused by ear trauma/injury, see that protocol

TRIAGE ASSESSMENT QUESTIONS

Call EMS 911 Now

Sounds like a life-threatening emergency to the triager

See More Appropriate Protocol

Painful ear canal and has been swimming

Go to Protocol: Ear - Swimmer's (Pediatric) Full or muffled sensation in the ear, but no pain Go to Protocol: Ear - Congestion (Pediatric)

Due to airplane or mountain travel

Go to Protocol: Ear - Congestion (Pediatric) Crying and cause is unclear Go to Protocol: Crying - 3 Months and Older (Pediatric)

Follows an injury to the ear

Go to Protocol: Ear Injury (Pediatric)

Go to ED/UCC Now (or to Office with PCP Approval)

Fever and weak immune system (sickle cell disease, HIV, chemotherapy, organ transplant, chronic steroids, etc)

R/O: serious bacterial infection Child sounds very sick or weak to triager R/O: sepsis

Go to Office Now

Stiff neck

R/O: meningitis

Walking is unsteady and new-onset

Fever > 105? F (40.6? C)

R/O: serious bacterial infection

Telephone Triage Protocols: Pediatric Office Hours Version Copyright 1994-2020, Schmitt Pediatric Guidelines LLC

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Pointed object was inserted into the ear canal (e.g., a pencil, stick, or wire)

R/O: perforated eardrum, damaged ossicles

Earache is SEVERE 2 hours after taking pain medicine

Outer ear is red, swollen and painful R/O: cellulitis and risk for ear cartilage damage

See Today in Office

Age < 2 years and ear infection suspected by triager Reason: recognizes child too young to report earache Pus or cloudy discharge from ear canal

Pus on eyelids/eyelashes

R/O: otitis-conjunctivitis syndrome with amoxicillin resistant organism

Child with cochlear implant

R/O: ear infection

See Today or Tomorrow in Office

Earache (Exception: MILD ear pain that resolved) R/O: otitis media

See Within 3 Days in Office

Recurrent transient MILD ear pain

Triager thinks child needs to be seen for non-urgent problem

Caller wants child seen for non-urgent problem

Home Care

Transient (or resolved) MILD ear pain once Reason: transient eustachian tube blockage

HOME CARE ADVICE

Suspected Ear Infection (Treatment Pending Office Visit)

1. Reassurance and Education: Your child may have an ear infection, but it doesn't sound serious. The only way to be sure is to examine the eardrum. Diagnosis and treatment can safely wait until morning if the earache begins after office hours.

2. Pain Medicine: Give acetaminophen (e.g., Tylenol) or ibuprofen for pain relief.

3. Cold Pack for Pain: Apply a cold pack or a cold wet wash cloth to the outer ear for 20 minutes to reduce pain while the pain medicine takes effect.

Telephone Triage Protocols: Pediatric Office Hours Version Copyright 1994-2020, Schmitt Pediatric Guidelines LLC

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Note: Some children prefer local heat for 20 minutes.

4. Olive Oil Eardrops for Persistent Pain: Do not recommend any eardrops if the child will be seen today. (Reason: May make it difficult to visualize the eardrums.) For severe earache unresponsive to oral pain medicine, recommend 3 drops of plain olive oil into the ear canal. Another option is plain mineral oil (baby oil). Repeat every 4 hours as needed. Exception: ear discharge, ear tubes or hole in eardrum. U.S. Update: Prescription analgesic ear drops that contain benzocaine-antipyrine are no longer available in the US (FDA 2015 regulation). Canada: Auralgan eardrops are available OTC in Canada. Can recommend for severe pain.

5. Fever Medicine: For fever above 102 F (39 C), give acetaminophen every 4 hours OR ibuprofen every 6 hours as needed. (See Dosage table) For fevers 100-102 F (37.8 to 39 C), fever medicines are not needed. Reason: Fever turns on your body's immune system. Fever helps fight the infection.

6. Avoid Earplugs: If pus or cloudy fluid is draining from the ear canal, the eardrum has ruptured from an ear infection. Wipe the pus away as it appears. Avoid plugging with cotton (Reason: Retained pus causes irritation or infection of the ear canal).

7. Contagiousness: Ear infections are not contagious.

8. Call Back If: Your child develops severe pain Your child becomes worse

9. Extra Advice - Request for Antibiotics by Phone: Inform caller that PCPs rarely call in antibiotics without examining the ear. Reassure that ear pain can be controlled with analgesics and eardrops. Reassure that examining child within 24 hours is quite safe.

Transient (or Resolved) Mild Ear Pain Once

1. Reassurance and Education: Transient ear pain once that goes away is harmless. This kind of pain is sometimes caused by a blocked eustachian tube that opens up on its own. Since the pain has gone away, no treatment is necessary.

2. No Pain Medicines: Don't give pain medicines. Reason: If earache recurs, your child will need to be seen in the office.

3. Call Back If: Pain recurs

FIRST AID

N/A

Telephone Triage Protocols: Pediatric Office Hours Version Copyright 1994-2020, Schmitt Pediatric Guidelines LLC

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BACKGROUND INFORMATION

Pain Severity Scale

Mild: doesn't interfere with normal activities Moderate: interferes with normal activities or awakens from sleep Severe: excruciating pain, unable to do any normal activities, incapacitated by pain Assessment of Pain Severity: Base it on the child's current behavior. Ask: "What does the pain keep your child from doing?" Do not ask: "Is the pain Mild, Moderate or Severe?" Reason: Many parents and teens will choose "Severe".

Causes of Earaches

Ear Infection. An infection of the middle ear (space behind the eardrum) is the most common cause. Ear infections can be caused by viruses or bacteria. Usually, a doctor can tell the difference by looking at the eardrum. Swimmer's Ear. An infection or irritation of the skin that lines the ear canal. Main symptom is itchy ear canal. If the canal becomes infected, it also becomes painful. Mainly occurs in swimmers and in the summer time. Ear Canal Injury. A cotton swab or fingernail can cause a scrape in the canal. Ear Canal Abscess. An infection of a hair follicle in the ear canal can be very painful. It looks like a small red bump. Sometimes, it turns into a pimple. It needs to be drained. Earwax. A big piece of hard earwax can cause mild ear pain. If the wax has been pushed in by Qtips, the ear canal can become blocked. This pain will be worse. Ear Canal Foreign Body (Object). Young children may put small objects in their ear canal. It will cause pain if object is sharp or pushed in very far. Airplane Ear. If the ear tube is blocked, sudden increases in air pressure can cause the eardrum to stretch. The main symptom is severe ear pain. It usually starts when coming down for a landing. It can also occur during mountain driving. Pierced Ear Infections. These are common. If not treated early, they can become very painful. Referred Pain. Ear pain can also be referred from diseases not in the ear. Tonsil infections are a common example. Tooth decay in a back molar can seem like ear pain. Mumps can be reported as ear pain. Reason: the mumps parotid gland is in front of the ear. Jaw pain (TMJ syndrome) can masquerade as ear pain.

Analgesic Eardrops - No Longer Available (FDA 2015)

2015 FDA major change: Benzocaine-antipyrine ear drops have never been approved by the FDA. As of July 2015, they will no longer be available in U.S. pharmacies. Reason the FDA gives for this enforcement: Unproven effectiveness (not because of side effects). Previous information found in this protocol: Analgesic eardrops have long been prescribed in selected patients to reduce severe pain from otitis media (Hoberman 1997). Many teen and adult patients insist that these products give them pain relief. Generic analgesic eardrops and brand name Auralgan eardrops have identical ingredients (benzocaine and antipyrine). Both are prescription drugs in the U.S. In 2008, Deston Therapeutics, the company that makes Auralgan, changed the formulation and increased the price to $140/bottle. In the U.S., only generic analgesic ear drops had been previously recommended because of cost-savings. Canada: Can use Auralgan eardrops for severe pain. Reason: Available OTC in Canada.

Return to School

An earache or ear infection is not contagious. No need to miss any school or daycare.

Telephone Triage Protocols: Pediatric Office Hours Version Copyright 1994-2020, Schmitt Pediatric Guidelines LLC

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Matching Pediatric Handouts for Callers

Printed home care advice instructions for patients have been written for this guideline. If your software contains them, they can be sent to the caller at the end of your call. Here are the names of the pediatric handouts (ACIs) that relate to this topic:

Earache - From Air Travel Earache - Symptom Fever - How to Take the Temperature Fever - Myths Versus Facts Acetaminophen (Tylenol) Dosage Table - Children Ibuprofen (Advil, Motrin) Dosage Table - Children

REFERENCES

1. Bales CB, Sobol S, Wetmore R, Elden LM. Lateral sinus thrombosis as a complication of otitis media: 10-year experience at the Children's Hospital of Philadelphia. Pediatrics. 2009;123:709-713.

2. Bolt P, et al. Topical lidocaine eardrops reduce pain in AOM. Arch Dis Child. 2008;93:40-44.

3. Canadian Paediatric Society, Infectious Diseases and Immunization Committee. Management of acute otitis media. Paediatr Child Health. 2009;14(7):457-460.

4. Canto RM. Otitis externa and otitis media: A new look at old problems. Emerg Med Clin North Am. 1995;13:445-455.

5. Gould JM, Matz PS. Otitis media. Pediatr Rev 2010;31:102-115.

6. Hoberman A, et al. Efficacy of Auralgan for treating ear pain in children with acute otitis media. Arch Pediatr Adolesc Med. 1997;151:675-678.

7. Laine MK, Tahtinen PA, Ruuskanen O, et al. Symptoms or symptom-based scores cannot predict acute otitis media at otitis-prone age. Pediatrics. 2010 May;125(5):e1154-1161.

8. Licameli GR. Diagnosis and management of otalgia in the pediatric patient. Pediatr Ann. 1999;28(6):364-368.

9. Lieberthal AS, Carroll AE, Chonmaitree T, et al. American Academy of Pediatrics Clinical Practice Guideline: Diagnosis and management of acute otitis media. Pediatrics. 2013;131:e964-e999.

10. Maxson S and Yamauchi T. Acute otitis media. Pediatr Rev. 1996;17:191-195.

11. McWilliams DB, Jacobson RM, Van Houten HK. A program of anticipatory guidance for the prevention of emergency department visits for ear pain. Arch Pediatr Adolesc Med. 2008;162(2):151-156.

12. Pirozzo S, Del Mar C. Otitis media. In: Moyer V, Davis RL, Elliott E, et al, eds. Evidence Based Pediatrics and Child Health. London, England: BMJ Publishing Group; 2000. p. 238247

13. Shaikh N, Hoberman A, Rockette HE, et al. Development of an algorithm for the diagnosis of otitis media. Acad Pediatr. 2012;12:214-218.

14. Uitti JM, Laine MK, Tahtinen PA, et al. Symptoms and otoscopic signs in bilateral and unilateral acute otitis media. Pediatrics 2013;131:e398-e405.

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